April 1st, 2016

Insurance department examines handling of claims

To address the opioid addiction issue in New Hampshire and barriers to care, the state’s insurance department began “a targeted examination” in November 2015 of how insurance companies handle claims related to substance use disorders.

A preliminary look at claims from January to September 2015 by an independent review organization found that eight of 64 medical necessity denials were challengeable, according to the department. That was out of 11,650 total claims for substance used disorder services. Of the eight denials, five involved disagreement on the level of care needed, such as inpatient or intensive outpatient.

“This could indicate a potential lack of understanding regarding the need for short-term inpatient withdrawal management versus indefinite inpatient admission,” said Danielle Kronk Barrick, spokeswoman for the New Hampshire Insurance Department, in an email.

Examiners did not find any legal violations in terms of notices provided to consumers, the department said.

The examination, which is expected to be completed this summer, looked at the top three insurers’ networks for substance use disorder claims for inpatient, intensive outpatient, rehabilitation,and licensed addiction counselors.

“A shortage of contracted providers was identified for each insurer in certain counties,” Kronk Barrick said. “The examination found that while the state’s network adequacy standards were met, the concern throughout the state as to the availability of providers appears to be consistent with the insurers’ identification of gaps in access.”

The department began looking at substance use disorder claims to see how insurance companies handled claims, preauthorization, claim denials and utilization review practices, according to a news release. The department also analyzed consumers’ access to providers of substance use disorder treatment, the network of treatment providers, and the system for handling claim denial appeals.

“The goal is to bring factual basis to the ongoing discussion of barriers to care and how changes in insurance companies’ practices and/or changes to insurance laws could help eliminate those barriers,” said Kronk Barrick.

Preliminary findings were presented to the Governor’s Commission on Drug and Alcohol Abuse Prevention, Treatment and Recovery in February.

“Under New Hampshire and federal law, insurance policies that cover treatment for mental health conditions – including substance use disorder and addiction – must do so in the same manner and to the same degree as they cover conditions relating to physical health,” said New Hampshire Insurance Commissioner Roger Sevigny in a prepared statement.

The department is also taking other steps to make sure consumers receive the full benefits of their coverage, including creating an outreach and education position within the department, partnering with the University of New Hampshire School of Law to create a consumer tool kit, and organizing a stakeholder group that will meet regularly to set priorities and examine progress, said Kronk Barrick.

“We’re very encouraged by the steps that the New Hampshire Insurance Department has taken,” said Ken Norton, executive director of the New Hampshire chapter of the National Alliance on Mental Illness. “Although this last market conduct analysis focused on parity issues related to substance use disorders, we’re hopeful that in the future they will do a similar analysis on issues related specifically on parity issues related to mental health disorders.”

By Rivkela Brodsky

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